Nephrology
Clinical discussions on kidney disease management, dialysis, transplantation, and electrolyte disorders.
Recent Discussions
What is your approach to initiating spironolactone in patients with end stage kidney disease and heart failure?
Not sure that we have a consensus answer for this question, but spironolactone in hemodialysis patients likely causes more harm than good.There are data suggesting that spironolactone increases the risk for arrhythmia (heart block or bradycardia; Mc Causland et al., PMID 36763641) and hyperkalemia (...
Do you perform a repeat kidney biopsy in a patient with IgA nephropathy who has achieved partial proteinuria reduction on current therapy but has not reached the target of below 1 g per day, to assess residual histologic activity before escalating treatment?
I would not recommend a routine repeat biopsy to assess residual histologic activity before escalating therapy for a partial proteinuria response in IgA nephropathy (IgAN). Instead, I base treatment escalation entirely on clinical trajectory, specifically persistent proteinuria (>1 g/day or ≥0.5 g/d...
Has the MAJESTY trial changed your approach to the rituximab versus obinutuzumab choice in a patient with newly diagnosed primary membranous nephropathy and nephrotic syndrome?
The Bottom Line: Recent landmark trials—MENTOR and MAJESTY—confirm that anti-CD20 therapies are superior to calcineurin inhibitors (CNIs) for the treatment of MN.Key Trial DataMENTOR: Demonstrated that RTX was noninferior to cyclosporine at 12 months, and decisively superior by 24 months (60% vs. 20...
What is your approach to treating concomitant hypernatremia and hyperglycemia in patients with encephalopathy?
The risk-benefit assessment begins by identifying the primary physiologic problem. In patients with concomitant hypernatremia and hyperglycemia, the dominant abnormality is usually a profound free water deficit from osmotic diuresis. My goal is to restore normal physiology by replacing that free wat...
How do you approach vitamin D supplementation in patients with chronic kidney disease, given the findings that vitamin D2 supplementation may lead to decreased conversion of 25-hydroxyvitamin D3 to 1,25-dihydroxyvitamin D3?
In early 2000, there was a publication suggesting that ingesting vitamin D2 increases the destruction of vitamin D3 and therefore could increase the risk for vitamin D deficiency. Although I had never seen this happen in my clinic, we decided to conduct a study to evaluate what the effect of vitamin...
Is there a serum phosphorus level you would consider too low to safely perform hemodialysis?
I actually do. I have previously published reports of 2 patients who developed recurrent encephalopathy due to dialysis-induced hypophosphatemia. They were treated with adding phosphorus to the dialysis fluid and the episodes did not recur (Koganti & Sam, PMID 31940631). I definitely do not want the...
What is your treatment approach when managing patients with relapsing lupus nephritis who previously achieved remission with mycophenolate and steroids?
Remember that each lupus nephritis (LN) flare is accompanied by permanent loss of nephrons, as much as a third! Each flare increases the risk for poor response (Perez-Arias et al., PMID 36318456). Relapse is not to be taken lightly.I am a big believer in considering combination therapy as initial th...
How do you approach patients who are inappropriately worried/fixated on a test result that is flagged as abnormal but not clinically significant?
This happens all the time now. I tell them that those results were flagged as outside the reference range (I don't use the term abnormal) but that they are not clinically significant. It does not always work if there is a patient who is super anxious or hyper-focused. Typically, if they need a lot m...
What is your approach to management of severe hyponatremia in patients with alcohol use disorder who experience seizures that could be secondary to the electrolyte derangement or alcohol withdrawal?
Since it is difficult to make a definitive distinction as to whether the seizure is due to severe hyponatremia or alcohol withdrawal, it is prudent to treat both severe hyponatremia and alcohol withdrawal concurrently. Given that the seizure may be contributed to by the severe hyponatremia, 3% hyper...
Do you recommend adding Moonstone supplements for patients with recurrent calcium oxalate nephrolithiasis who are on potassium citrate but continue to have hypocitraturia?
As an inventor of Moonstone Stone Stopper, I do have a conflict of interest. Having disclosed that, I will say that it is a good way to supplement citrate. Many of my patients use BOTH K citrate and Moonstone depending on whether they have bathroom access, are traveling, or the like. Many take the t...